Euro Psychiatry 2020 The Influence of Brain Lesion on Stand-Alone Anterior Cervical Decompression and Fusion in Three Levels with Peek Cages: A Possible Satisfactory Alternative
Anterior cervical decompression and fusion (ACDF) remains the gold standard for subaxial degeneration of anterior elements. By multilevel stenosis corpectomy or instrumentation with screws and plate are supported. Their potential complications, though, should be reckoned. The use of polyetheretherketone (PEEK) cages packed with demineralized bone matrix (DBM) alone can provide good fusion rates and clinical improvement even in cases of three levels degeneration. The purpose of this paper is to present retrospectively the outcomes of 15 patients with cervical stenosis in three levels treated with cage implantation reviewing the relevant literature, too. Anterior cervical decompression and fusion (ACDF) remains the gold standard for sub axial degeneration of anterior elements . In cases of multilevel stenosis more recent methods such as corpectomy  or instrumentation with screws and plate are supported . Their complications, though, concerning failure or dislocation of material and adjacent neurovascular structures injury, as well, should be reckoned [2,4]. The use of polyetheretherketone (PEEK) cages packed with demineralized bone matrix (DBM) alone can provide good fusion rates and clinical improvement even in cases of three levels degeneration . Although Class-I evidence, thereof, do not exist stand-alone cage placement could be an alternative for patients with major comorbidities. The purpose of this paper is to present a retrospectively assessed series of 15 patients with cervical stenosis treated in three levels reviewing the literature, as well. Materials and Methods 15 patients were operated in three levels from 2012 until 2015 presenting with either mild myelo/radiculopathy or severe myelopathy. Patients with traumatic, infectious or neoplasmatic stenosis were excluded. Their mean age was 58 years-old. Male individuals were 9 and female 6. Nine of the patients underwent a onestage operation, five of them a twostage and one patient were operated in three phases. By all patients the classical method, as it was described by Smith and Robinson  under microscope was followed. Our aim was to avoid excess distraction, resecting initially the most anterior of the superior endplate like a “cap” using a Kerrison rongue providing thus surgical plane for sufficient disc removal. Further disc removal was performed using preferably only a rongue, too, except of cases of massive osteophyte formation. The disc, posterior longitudinal ligament and osteophytes were extracted decompressing consequently the foramina; endplate cartilage was also curetted. Cages were filled with demineralized bone matrix (DBM) and their position was controlled radiographically. Platysma was then closured and afterwards the subcutaneous layer and cutis separately. Postoperatively patients wore a soft collar for ten days. References: Sampath P, Bendebba M, Davis JD, Ducker TB (2000) Outcome of patients treated for cervical myelopathy: A prospective multicentre study with independent clinical review. Spine 25: 670-676. Wang JC, Panjabi MM, Isomi T (2000) The role of bone graft force in stabilizing the multilevel anterior cervical spine plate system. Spine 25: 1649-1654. Wang JC, McDonough PW, Endow KK, Delamarter RB (2000) Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion. Spine 25: 41-45.
Wang JC, Mc Donough PW, Kanim LE, Endow KK, Delamarter RB (1976) Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion spine. 26: 643-646. Demicran MN, Kutlay AM, Colak A, Kaya S, Tekin T, et al. (2000) Multilevel cervical fusion without plates, screws or autogenous iliac crest bone graft. J ClinNeurosci 14: 723-728. Smith GW, Robinson RA (1958) The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion J Bone Joint Surg Am 40: 607-623. Ranawat CS, Oleary P, Pellici P, Tsairis P, Marchisello P, et al. (2000) Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg 61: 1003-1010. Cannada LK, Scherping SC, Yoo JU, Jones PK, Emery SE (2003) Pseudoarthrosis of the cervical spine: A comparison of radiographic measures Spine 28: 46-51. Hillibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH (1999) Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Surg Am 81: 519-528. Ishihara A (1968) Roentgenographic studies on the normal pattern of cervical curvature. Nippon Seikei Geka Gakkai Zasshi 42: 1033-1004. Vavruch L, Hedlund R, Javid D, Leszniewski W, Shalabi A (2002) A prospective randomized comparison between the Cloward procedure and carbon fiber cage in the cervical spine. Spine 27: 1694-1701. Kalsi-Ryan S, Singh A, Massicote EM, Arnold PM, Brodke DS, et al. (1998) Ancillary outcome measures for assessment of individuals with cervical spondylotic myelopathy. Spine 38: S111-122. Vernon H (2008) The Neck Disability Index: State-of-theart during 1991-2008. J Manipulative Physiol Ther 31: 491-502. Connolly PJ, Esses SI, Kostuik JP (1996) Anterior cervical fusion: Outcome analysis of patients fused with and without anterior cervical plates. J Spinal Disord 9: 202- 206. Epstein NE (2000) The value of anterior cervical plating in preventing vertebral fracture and graft extrusion after multilevel anterior cervical corpectomy with posterior wiring and fusion: Indications, results, and complications. J Spinal Disord 13: 9-15. Hee HT, Majd ME, Holt RT, Whitecloud TS 3rd, Pienkowski D (2003) Complications of multilevel cervical corpectomies and reconstruction with titanium cages and anterior plating. J Spinal Disord Tech 16: 1-8. Sun Y, Li L, Zhao J, Gu R (2015) Comparison between anterior approaches and posterior ap-proaches for the treatment of multilevel cervical spondylotic myelopathy: A meta-analysis. Clin Neurol Neurosurg 134: 28-36. Topuz K, Colak A, Kaya S, Simsek H, Kutlay M, et al. (2000) Two-level con-tiguous cervical disc disease treated with peek cages packed with demineralized bone ma-trix: Results of 3-yearfollow-up. Eur Spine J 18: 238-243. Cho DY, Liau WR, Lee WY, Liu JT, Chiu CL, et al. (2000) Preliminary experience using a polyetherether-ketone(PEEK) cage in the treatment of cervical disc disease. Neurosurgery 51: 1343-1350. Cho DY, Lee WY, Sheu PC (2004) Treatment of multilevel cervical fusion with cages. Surg Neurol 62: 378-386. Pereira EAC, Chari A, Hempenstall J, Leach JCD, Chandran H, et al. (2013) Anterior cervical discectomy plus intervertebral polyetheretherketone cage fusion over three and four levels without plating is safe and effective long-term Journal of Clinical Neurosci-ence 20: 1250-1255. Liu H, Ploumis A, Li C, Yi X, Li H (2012) Polyetheretherketone cages alone with allograft for three-level anterior cervical fusion ISRN Neurology 2012: 5. Simsek H (2017) Anterior cervical discectomy and fusion solely with peek cages in multilevel cervical spondylotic radiculomyelopathy: A single center clinical experience with 58 consecutive patients Medicine Science 6: 514- 520. Song KJ, Kim GH, Choi BY (2011) Efficacy of PEEK cages and plate augmentation in three-level anterior cervical fusion of elderly patients. Clin Orthop Surg 3: 9-15.